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In-hospital cost of percutaneous coronary revascularization. Critical determinants and implications
S G Ellis1, D P Miller, K J Brown
1Department of Cardiology, Cleveland Clinic Foundation, OH 44195, USA.
Insights
Hospital costs for percutaneous transluminal coronary revascularization (PTCR) vary widely. Patient factors, procedural complications, and system delays significantly influence these costs, highlighting opportunities for more efficient care.
Area of Science:
- Cardiovascular Medicine
- Health Economics
Background:
- Percutaneous transluminal coronary revascularization (PTCR) procedures incur substantial hospital costs in the United States, exceeding $6 billion in 1994.
- Limited understanding exists regarding the primary factors driving the significant cost variability associated with PTCR.
Purpose of the Study:
- To identify and analyze the key clinical, angiographic, physician, and outcome variables that correlate with the total cost of PTCR.
- To quantify the determinants of cost variability in PTCR procedures.
Main Methods:
- Analysis of 1258 attempted PTCR procedures at a single tertiary referral center, with cost data available for 1237 procedures.
- Multivariate linear regression modeling was used to identify independent correlates of total cost (hospital and physician) and log-transformed cost (loge(cost)).
- Variables analyzed included patient demographics, clinical presentation, procedural details, complications, and system-related delays.
Main Results:
- The median cost for PTCR was $9176, with a wide interquartile range ($7333 to $13,845) and total range ($3422 to $193,474).
- Preprocedural factors like acute myocardial infarction, decision delays, weekend intervention, use of intra-aortic balloon counterpulsation, intent to stent, elevated creatinine, and lesion complexity were significant cost predictors (R2 = .37).
- Postprocedural factors including length of stay, urgent bypass surgery, specific devices used, myocardial infarction, creatinine rise, and blood transfusion also strongly correlated with cost (R2 = .82 with length of stay).
Conclusions:
- Total hospital costs for percutaneous coronary interventions exhibit extraordinary variability.
- Baseline patient characteristics explain a significant portion of cost variance, with procedural complications and system delays accounting for the remainder.
- Quantifying cost determinants can facilitate the development of more economically efficient healthcare practices for PTCR.
Background:
Hospital charges associated with percutaneous transluminal coronary revascularization (PTCR) in the United States exceeded $6 billion in 1994 and are likely to be constrained in some manner in the near future. Despite this high cost to the public, little is known about the major determinants and sources of variability of PTCR.
Methods And Results:
From a consecutive series of 1258 procedures with attempted PTCR at a single tertiary referral center, we analyzed 65 clinical, angiographic, physician, and outcome variables as potential correlates of total (hospital and physician) cost. Direct and indirect costs, both hospital and physician, were determined on the basis of resource utilization using "top-down" methodology and were available for 1237 procedures (1086 patients) (98.3%). Mean (+/- SD) patient age was 62 +/- 11 years, 76% were male, 3% had acute myocardial infarction, 71% had unstable angina, 58% had multivessel disease, left ventricular ejection fraction was 54 +/- 12%, 26% had use of at least one nonballoon revascularization device, and median length of stay was 4.4 days. Procedural success was obtained in 89%, and major complications (death, bypass surgery, or Q-wave myocardial infarction) occurred in 3.8%. The median cost was $9176, but it was asymmetrically distributed, and the interquartile and total ranges were wide ($7333 to $13,845 and $3422 to $193,474, respectively). Analyses of independent correlates of cost and loge(cost) were performed using multivariate linear regression in training and test populations. Modeling found 15 independent preprocedural correlates of loge(cost) (R2 = .37) and 23 overall correlates (R2 = .65), excluding length of stay per se. Additional of length of stay to the model increased the explanatory power of the model to R2 = .82. Preprocedural variables most predictive of loge(cost) included presentation with acute myocardial infarction, decision delay (> 48 hours between admission and diagnostic angiography and/or > 24 hours between angiography and intervention), weekend delay, use of intra-aortic balloon counterpulsation, intention to stent, creatinine > or = 2.0 mg%, and lesion complexity (modified American College of Cardiology/American Heart Association score) (all P < .001). In the model that included postprocedural variables as well, length of stay, noncardiac death, urgent bypass surgery, use of the Rotablator, Q-wave myocardial infarction, rise in creatinine > or = 1.0%, and blood product transfusion were all strong independent correlates of loge(cost) (P < .001).
Conclusions:
The range of total hospital costs associated with percutaneous intervention is extraordinarily wide. Baseline patient characteristics account for nearly half of the explained variance, but procedural complications and system delays account for much of the remainder. Quantification of the determinants of cost may promote more economically efficient care in the future.